11

Promoting health and well-being through socialism

Socialism and Health

The journal of the Socialist Health Association Autumn 2005

Editorial

In this issue we report from the Annual Conference of the Labour Party, to which the SHA submitted a contemporary motion on Public Health and Inequalities. The main health debate centred on two opposing resolutions on the Future of Health Service, the involvement of the private sector, the pace of change and the consequences for patients and staff. This subject has also been hotly debated at the Central Council of the SHA prior to the launching of the campaign to Keep the NHS Public. The issue centres around whether the SHA would be more effective in outright opposition to current Government policy, or in continuing to seek a dialogue with ministers and concentrating on debating particular areas of concern with arguments and facts. Central Council has approved the statement of Mission, Values and Aims which we reproduce below.

We also report on the Black Report 25th Anniversary conference held in Manchester in September.

Gavin Ross, Hon Editor

MISSION, VALUES AND AIMS

This statement was agreed by Central Council in September 2005

1.OUR MISSION - OR WHAT ARE WE FOR?

To promote health and wellbeing, social justice, and the eradication of inequalities through the application of socialist principles to society and government.

This clearly includes the three original aims of the SHA as set out in 1930. The new ingredient which dominates public health and socialist thinking at the beginning of the third millennium is the reduction and ultimate eradication of inequalities.

To achieve this MISSION we believe that we need to be an actively campaigning organisation as well as one that supports critical debate about the wide range of issues that comprise health and wellbeing in the third millennium. We want to make a difference by having influence at the highest level, that is on the government and on the Labour Party as well as on other bodies that influence them such as trade unions and on other socialist societies.

2. OUR CORE VALUES

Underpinning our Mission are three core values :

DEMOCRACY informed participation with election not selection

EQUALITY of opportunity and respect supported by affirmative action

UNIVERSAL HEALTHCARE meeting the prevention, treatment, rehabilitation and care needs of all, publicly provided, free at the point of use and funded by general taxation.

Underpinning these core values are seven guidelines for action :

PREVENTION AS WELL AS TREATMENT investment in prevention of disease as well as on treatment

WIDER DETERMINANTS AS WELL AS HEALTHCARE recognition that the wider determinants such as income, education and employment are as important in promoting the nations health as healthcare

INTERNATIONALISM recognition of the UKs international obligations to developing nations in respect of trade agreements and the importation of scarce healthcare personnel

SOLIDARITY working in close collaboration with other like minded bodies such as trade unions and the other socialist societies

LOCALISM decision making as near as possible to where it will have impact and at community level wherever practicable

AN INTEGRATED, WHOLE SYSTEMS APPROACH health, social care and wellbeing services provided through partnership working as integrated packages tailored to the needs of user, not the convenience of providers

COOPERATIVE ENDEAVOUR a cooperative approach to the running of public, voluntary and private sector services with worker and user participation

3. OUR PRIORITY AIMS

It is not possible to espouse every good causes so we will concentrate our efforts on those issues which we consider to be central to the attainment of our Mission:

Reducing inequalities in health particularly for disadvantaged groups such as the mentally ill; and for vulnerable groups particularly children

Local democratic control of the NHS including giving patients a voice at local and national levels

Defending and extending the NHS including securing adequate public funding, and removing all costs to users such as prescription charges and travel costs

Promoting healthy lifestyles through the provision of easy to understand and quality assured information to empower the public and through countering the influence of anti-health forces and any other factors which undermine this empowerment.

4. ACHIEVING OUR PRIORITY AIMS

To achieve these aims we will actively campaign both in our own right and, where appropriate, in collaboration with other like- minded organisations.

LABOUR PARTY ANNUAL CONFERENCE 2005 Gavin Ross and Martin Rathfelder

Labours Annual Conference at Brighton was intended as a celebration of the third successive election victory, and a commitment to more radical policies before Tony Blair decides to hand over to his successor. The platform did not have it all its own way: delegates chose subjects for debate critical of government policy, and delivered a series of defeats, while the media were only interested in the Blair-Brown question, until the diversion afforded by the ejection of Walter Wolfgang for interrupting Jack Straw when he mentioned Iraq.

The SHA submitted its contemporary resolution on Public Health (text below) which stood apart from the series of motions from UNISON and some CLPs on the Future of the Health Service. Delegates on arrival were given only two hours in which to vote for four topics, four from unions and affiliates and four from CLPs. There was little chance if any for delegates to read the 60 pages of resolutions. The result was that the Future of the Health service was selected by both unions and CLPs, while the SHA motion came a respectable 8th in the CLP section, not far behind Iraq which was 6th and therefore not debated. The compositing process produced two contrasting motions on the Future of the Health Service (see below), for which your delegate was able to support the Unison motion, which was supported almost unanimously by the unions and affiliates, and 42% of the CLPs, while the alternative motion obtained almost exactly the reverse vote. It was notable that speakers supporting the CLP resolution spoke mainly from a patient point of view, while those supporting the Unison motion expressed concerns about the effects on staff and the consequences if things went wrong.

Two SHA fringe meetings were held: a very successful joint meeting with the Labour Housing Group on Fuel Poverty, and a less well supported meeting on Health Outside Hospital. We had to compete with wealthier organisations who signed up to a series of health-related meetings at the Health Hotel, whose prices were well outside our range. At the Socialist Societies stall we handed out postcards to the Health Minister asking for a full ban on smoking in public places. (On a neighbouring stand the tobacco lobby, Forest, attempted to impress delegates about the evils of any ban, with a series of quotations from left-wing publications like the Mail on Sunday, the Spectator and the Daily Express). At the televised Question and Answer Session with the Health team we were able to ask a question on the effect of proposed changes on the widening inequalities in health revealed by the recent Marmot Report. At this point viewers were returned to the studio, so the answers were not heard!

The SHA Motion will be referred to the National Policy Forum, but we are encouraged by the fact the Patricia Hewitt, the Health Secretary, has made very similar points in her recent pamphlet The Nations Health and Social Change (New Health Network, September 2005).

Annual Conference is no longer the only decision-making occasion for the Labour Party. Policy-making evolves gradually, but what many find frustrating is the appearance of new policies from apparently nowhere, with the need to understand, debate and criticise as necessary whenever they are announced.

SHA Contemporary Resolution: Public Health and Inequality

Conference notes:

The report by Sir Michael Marmot and others: Tackling health inequalities: Status report on the Programme for Action published on 11th August shows a continuing widening of inequalities as measured by infant mortality and life expectancy at birth.Proposals made by the Secretary of State for Health on 19th July and subsequently to introduce wide ranging consultations about the future of health and social care and of democratic involvement in their governance.The decision announced on 2nd August to postpone the abolition of the Commission for Public and Patient Involvement in Health and to set up a review of public involvement and accountability in the NHS.In this month the 25th anniversary of the Black Report on Inequalities in Health it is appropriate to recall that its recommendations, like those of the much more recent Acheson Report, called for wide ranging action by all Departments of State not just the Department of Health.The publication on August 25th of research conducted by Dr Bhatti, Director of Public Health for Huddersfield which demonstrated that while admissions to hospital with heart attack was 38 % higher per head in deprived parts of that town the death rate was 317% higher.The absence of any mechanism in the Party where differences between policy in England and that in Scotland and in Wales may be discussed.

Conference calls on the Government in respect of England and Wales

1.To adopt a much bolder and more radical approach to public health including :

a complete ban on smoking in all public places with no exemptions as is proposed in Scotlanda comprehensive transport policy which both encourages physical exercise and reduces environmental pollution by promoting accessible and affordable public transport and by discouraging private motor car use by measures such as road use chargessubstantial improvements in the diet of children through a complete ban on advertising of processed foods except at point of sale and through provision of free healthy school meals to alleffective measures to ensure that the obstruction of breastfeeding mothers is a criminal offence as it is in Scotland.

2.To give much higher priority to public health and to make public health the direct responsibility of a cabinet minister.

3.To evaluate proposals for the reform of health and social care primarily in terms of their impact on health and social inequalities and equity.

4.To transfer responsibility for public health and the commissioning of health services at local level away from appointed quangos to elected Local Authorities so permitting the abolition of Primary Care Trusts with their unelected boards and high administrative overheads.

Motion referred to National Policy Forum.

Future of the Health Service: Composite 6 moved by UNISON

On July 28th, the NHS Chief Executive issued instructions to Primary Care Trusts (PCTs) and Strategic Health Authorities. This document sets out a programme for the opening of primary care to private providers. Primary Care Trusts currently provide the full range of community health services such as district nursing, health visiting and occupational therapy. The DoH communication specifies that PCTs will becoming commissioning-led organisations with their role in provision reduced to a minimum and directs that a range of providers be introduced to ensure competition. This marks a very significant change in the way community health services are to be delivered, threatening job losses and a major expansion of the private sector into our NHS. The instructions also set an impossible timetable for submissions and implementation. Conference believes that this crucial change in policy has not been debated within the Labour Party, repeating the mistakes made in the announcement of Foundation Hospitals, and is poorly understood by the public.

Labour came to power in 1997 pledged to abolish the NHS internal market and deliver world class public services through sustained investment and reform. A programme of reform has been implemented alongside the large sums spent on public services. The NHS is delivering the vision of modernisation set out in the NHS Plan. The staff on the NHS are meeting the targets and reducing waiting list times and their contributions are consistently praised by ministers and Labour MPs.

However, since 2002 reforms have centred on increasing the role of the private sector and the creation of markets, rather than empowering NHS staff to work together to bring about desired improvements. PFI and contracting out have continued and markets have been introduced in the NHS, through pricing mechanisms, competition and the development of foundation hospitals. Conference is concerned that in its third term our Government has accelerated the implementation of the policy of establishing a full-scale market system in health. In addition the government with its choice agenda is insisting that every patient requiring routine surgery is given the choice of five or six providers, at least one of which must be a private health care company. These latter companies generally do not have the intensive care back-up facilities should an operation go wrong. In such situations, the patient has to be transferred to the NHS and to the NHS budget.

The 28 July announcement included the notification of the roll out of foundation trust status to all hospitals and to the ambulance service. This follows the decision by the Secretary of State to give 3 billion to the expansion of independent treatment centres (ISTCs). In addition there are inexplicable plans to further outsource successful services such as NHS Logistics and decontamination services, demoralising hard working, dedicated staff who have delivered for the NHS and patients.

In the future Health Services are to be delivered by a range of different providers, who, rather than collaborating together to exchange good practice and plan services, will compete to attract the most profitable users. Hospitals are being made independent of Government, and left to stand or fall on their ability to break even, with those that are not able to being allowed to close. In place of public accountability, decisions about the nature and pattern of service provision will increasingly be driven by profitability and the logic of the market.

Conference is convinced that these changes risk undermining service quality, and will lead to greater inequality of access by replacing the principle of service provision based on need with service provision based on profitability. Time and time again in our public services from the railways to residential care, school meals to the NHS internal market we have seen the way in which outsourcing and the creation of markets has led to higher costs, service failure and fragmentation, and worse terms and conditions for staff.

There can be no doubt that the 28 July instructions to PCTs represent a clear direction of travel towards fragmenting the NHS and embedding a marketised system of providing public services with a substantial and growing role for the private sector.

Surveys have shown that a large majority of the public are opposed to the increasing privatisation of the NHS (including a June YouGov poll showing that 89% of voters believe that public services should be run by the government or local authorities rather than by private companies and a Which? survey published on 1 August showing that 89% of respondents agreed that access to a good local hospital was more important than the Government giving people more hospitals to choose from).

The adverse effects of Government policies were recently highlighted in a report in the Which? magazine. This report concluded that: Choice is likely to foster differential access to care which will exacerbate existing inequalities in health and access to health care and may even create new ones depending on the individuals desire or ability to make or take up choices. Relying on market mechanisms and the operation of Payment by Results to stimulate new capacity is no guarantee that any additional capacity is actually what is needed or is provided where it is needed.

Conference believes that there has been no adequate assessment of the way in which this process is being carried out and of the longer-term consequences of these decisions.

Conference therefore calls on the Government to:

Consult with representatives of all levels of NHS management, the NHS unions and patient and professional bodies to clearly identify the practical shortcomings that are emerging with the choice and market policies in the NHS.Institute an urgent joint review into the mix of private sector provision in the NHS and the role, limits and regulation of markets in our public services.Suspend the introduction of competition of providers into primary care services, and the stipulation that the role of PCTs as service providers be minimized, pending the outcome of such a review.Suspend any further expansion of the role of the private sector into the NHSSuspend the second wave of Independent Sector Treatment Centres until an evaluation of the first wave is completed.

This motion was carried.

Future of the Health Service Composite 7 moved by Birmingham Hall Green CLP

Conference notes the Department of Healths consultation exercise on care out of hospitals Your Health, Your Care, Your Say launched in September 2005, and the publication of Commissioning a Patient-led NHS.

Conference reaffirms Labours commitment to a universal NHS, primarily funded by general taxation, free at the point of need. Conference welcomes the step-change in the governments investment in the NHS, which represents a trebling of resources by 2008 for health since 1997, welcomes the extra 27,000 doctors and 79,000 extra nurses in post or in training, and welcomes the improvements in pay and conditions for NHS workers resulting from Agenda for Change.

Conference recognises that for such massive investment to guarantee the long-term future of the NHS, there must be modernisation and reform of the system. These reforms must include improved pay, conditions and status for NHS workers, more flexibility and choice for patients, shorter waiting lists, and renewed effort to tackle health inequalities.

Conference urges government to re-examine the power of Health Authorities to decide arbitrarily upon the distribution of healthcare services within their area of administration. The purpose of the re-examination would be to ensure that any such decisions must be made with the full co-operation of stakeholders, e.g. hospital staff, patients and families, local authorities and local organisations representing the public and to ensure that Health Authority executives are made fully accountable for the roll-out and successful operation of agreed plans.

Conference welcomes the manifesto commitment to let patients decide which hospital they go to for their operation,, and to let women choose where and how they have their baby, and what pain relief to use.

Conference notes that the independent sector providers have played an important role in reducing waiting lists and providing care within the NHS, especially in deprived neighbourhoods and for the poorest people, including over 460,000 operations free at the point of need.

Conference believes that in order to safeguard the NHS for future generations, there must be reform of the system, more choice for patients, greater diversity of supplier and more NHS services in local neighbourhoods. To this end, conference welcomes the initiatives currently being undertaken by our Labour Government, and calls for a consultation with representatives of all levels of NHS management, the NHS unions and patient and professional bodies.

This motion was not carried.

Bev Hughes Minister for Children with Mr Oscar Rathfelder

BLACK REPORT 25th ANNIVERSARY CONFERENCE

Ursula Harries and Fiona Reynolds

If the Northwest of England fails to tackle its health inequalities by 2010, then it will be impossible for the country to do so. Health and income inequalities under New Labour are higher than they were before and during the Thatcher government and the government has failed to hit all but two of its own targets.

The Black Report Health Inequalities 25 Years On Socialist Health Association Conference, (Manchester, 09/09/2005) was further told that little has changed since the Black Report was published in 1980 with inequalities in life expectancy widening. Professor Richard Wilkinson from Nottingham University Medical School went as far as adding: This is the biggest social injustice and human rights abuse in the developed world.

Minister for Children, Beverley Hughes, reiterated New Labours commitment to reducing health inequalities. She quoted Brian Abel Smith, the leading Fabian and LSE academic, who wrote in 1984:

"If socialists believed forty years ago that all that was needed to equalise health status between social classes was to remove the money barriers to access to health care, they were seriously mistaken."

She accepted that the middle classes were disproportionately benefiting from the NHS. She emphasised the need for concerted action across government and detailed, relentless strategies to try and tackle various aspects of inequalities because, she said, improvements in income are a necessary condition for reducing health inequalities, they are not in themselves sufficient. Rises in income have to be related with changes in life style and behaviour in order to maximise the impact on health: in diet; in smoking in sexual health. She stressed the contribution childrens centres and childrens trusts would make to improving childrens life chances, but that it would take time for results to be visible.

That NHS reform is going to continue was left beyond doubt, though the Minister seemed to believe that people do not care who is providing healthcare services. This point was later disputed by Dr Alex Scott-Samuel (University of Liverpool), citing public loyalty to the NHS. He said: It doesnt matter whether it is tuberculosis or coronary heart disease killing people as long as capitalism, in its current political and economic policy form, exists health inequalities will remain.

The impact of inequality in society upon health, and indeed society, was discussed at length by all of the speakers. Professor Wilkinson pointed out that more egalitarian societies do not have social problems on the scale that the UK has. Although he conceded that the health gap may have been wider without the Labour governments tax and benefit reforms, the improvements in child health have resulted in 1 in 5 children living in poverty as opposed to the previous 1 in 4.

And thats about as far as we can go in discussing what has changed, he said.

Regional Director of Public Health, Professor John Ashton pointed out that the Northwest has the highest concentration of health inequalities in the UK, and arithmetic shows that if it does not meet its targets, England as a whole will fail to do so. He also suggested that: Public Health is an after-thought when the furniture of the NHS is moved.

Dr S Bhatti, Director of Public Health for Huddersfield, demonstrated the power of technical advance over the last 25 years by showing the conference in great detail the extent of health inequalities in that area using Mosaic software. The immense difference in health inequalities had dominated the Huddersfield Examiner for weeks.

The final statements of action from the Conference were calls for a more equal society. James Munro (Editor of Health Matters) showed that this is not a new concept and concluded that: We are not seeking a perfect utopia, we are simply asking for a society like the one we had before.

In the light of the conference the Socialist Health Association tabled a resolution to the Labour party Conference demanding bolder action on public health.

A fuller report can be found at

http://www.sochealth.co.uk/confs/Blackconf.htm

A VIEW FROM THE CHAIR - Paul Walker

Crime and Disease the fruits of inequality

A postscript to my last piece which was a diatribe against the NHS in the light of my wifes recent unfortunate experience. The post of Chair of the relevant NHS Trust happened to come up so I applied making it clear in my application that my aim as Chair would be to try to improve the low standard care provided in one of its major hospitals. Inevitably, I was not shortlisted.

So, I have exercised my new rights under the Freedom of Information Act and I look forward to seeing what reasons were given for this decision. They obviously did not like the remedy I offered but I will be interested to see whether this was the reason given.

Changing tack completely, and with the events of 7/7 and 21/7 in mind the topic of crime and its links with health has occupied some of my thoughts recently. I have a long term personal interest in crime both as a regular victim a mugging at knife point in the US and two burglaries and three attempted car thefts in Bristol; and as a former Magistrate having adjudicated on a wide range of crimes. Some years ago, I got myself involved in a landmark study which sought to explore the links between crime and public health and the perceptions on such links among public sector policy makers. It transpired that there was a common belief that some types of crime and some aspects of ill health were related through having the same underlying causes: material deprivation, social exclusion, unemployment and poor education. It is no coincidence that the epidemic of crime of the last three decades has occurred at a time when, as documented in the Black Report, Margaret Whiteheads Health Divide and the Acheson Report of 1998, the health of the underprivileged in the UK has declined and inequalities in health have grown. Just as it is certain that men born into disadvantaged families will suffer more heart disease and cancer than their more advantaged peers so these same males in their teens will also have a much higher risk of being involved in criminal behaviour. Adolescent criminal behaviour and heart disease and cancer in middle age are manifestations of the same negative influences in early life.

Parallel with this epidemic there has been a growth of a new phenomenon, the fear of crime. The notion that the fear of crime is a problem in its own right emerged during the 1970s from the results of victimization surveys in the US. The British Social Attitudes Survey has from time to time attempted to measure the prevalence of the fear of crime by asking respondents whether worries about crime affected their everyday lives. One third of women and quarter of men answered in the affirmative, with older age groups more fearful than younger ones, especially young men who are, unsurprisingly, the most likely victims of violent crime.

So, the message comes over loud and clear that crime is not just an issue for the Police, the judiciary and the victims. It is very much an issue for all of us concerned with health and wellbeing and social justice. And in the end it all comes down to eliminating inequalities and improving the lives of deprived infants and children.

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Letter to the Editor from John Lipetz, Central Council member

Dear Editor,

At its most recent meeting the SHA Central Council took two major decisions: to approve a statement of Mission, Values and Aims which will guide the work of the SHA; and not to join the campaign to Keep Our NHS Public. The Mission statement is a sound document but the decision not to be a central part of the campaign runs in contradiction to these principles. Had the Tories introduced the so-called modernisation programme the SHA would be campaigning publicly, concerned at the risks it presented to the public ethos of the NHS and the equitable delivery of healthcare.

We have already experienced the PFI programme where Trusts involved will have huge yearly costs to pay for these developments out of limited revenue funding. Foundation Hospital Trusts undermine the SHAs aim to achieve a democratically controlled NHS.

The introduction of Independent (ie private) Sector Treatment Centres sets a market mechanism into place by establishing competition (contestability-sic!) between hospitals as well as with the private sector. PCTs are required to commission 15% of their funds in the independent sector, a creaming off of billions from the NHS. To bring private organisations into the market the government have set up long-term commitments at prices well in excess of what NHS units are paid.

Further, these treatment centres only take patients for a group of standard procedures. They are known to refuse patients with other conditions such as diabetes and angina. NHS hospitals must pick up any cases that are not routine as well as putting to rights those cases that go wrong. These centres do not make a contribution to the necessary training of junior doctors and nurses and, given that many routine operations are less commonly to be provided in the NHS, the experience and hence the quality of care provided by NHS surgeons and their teams could be undermined.

In primary care the government will shortly require PCTs to confine themselves to commissioning and not to provide services such as community nursing and health visiting. On the other hand, GPs (the major primary healthcare providers) are to be required to do the commissioning of secondary care for their patients. Surely, an inverted logic. Further, local improvement finance trusts (private of course) are taking over the ownership and control of some general practices and are being encouraged to widen the scope of their activities.

The statement put out by the campaign is unexceptional. In summary, it warns that income and profits will in time come before patients needs; greater inequalities will appear as the more profitable services and patients attract money; the NHS network of collaborative bodies will be split up by competition; and resources will be wasted administering a health market.

It is proper for the SHA to support those improvements to healthcare provision which the Labour Government has introduced but it is unacceptable to ignore the real risks to the populations health of policies developed by our government. For us, healthcare can never be regarded as just another commodity. Let us hope that SHA members will take a view on this issue that brings our Central Council back to its senses.

Yours sincerely,

John Lipetz

ROBIN COOK

The sudden death of Robin Cook on one of his favourite Scottish mountains shocked the Labour movement. While most tributes referred to his more recent activities, his role as opposition health spokesman around 1990 was extremely important. His attack on the Tory market-driven health reforms led by Kenneth Clarke is very relevant today, as illustrated by many of the items in this issue of Socialism & Health. Robin was a platform speaker at several of our conferences and fringe meetings, and his vision for health encompassed the whole range of government departments. A Fresh Start for Health, his manifesto for health in 1990, and his proposals for Public Health in The better way to a healthy Britain in 1991 contained many of the ideas promoted by the SHA, including curbs on tobacco and alcohol abuse, action to reduce inequalities in health, better dietary advice, warmer homes and access to clean water, a patient-friendly NHS with increased powers and resources for community health councils. His vision for NHS hospitals was that with high standards of excellence all round there would be no need for patient choice, and with increased provision there would be shorter waiting lists. Sadly in 1992 we did not have Robin as Health Secretary, and the rest is history.

Labour isn't working - Public Health News, October 17th 2005

Alex Scott-Samuel describes why government health inequalities policies are failing

Many people were surprised when the Tackling health inequalities status report, published in August, revealed that between 1997 and 2003, trends in both of the governments headline indicators which measure the social class gaps in life expectancy and infant mortality showed that health inequalities had in fact increased.

I wasnt as surprised by this as other NHS colleagues. Having closely followed progress on inequalities over the last 30 years, it seems to me that good intentions and effusive rhetoric are not enough to turn the tide. The only way to address inequalities is to eliminate their root causes.

People could, however, be forgiven for expecting better news. After all, Labours election victory in 1997 was followed by the Acheson report on health inequalities, along with a wide range of strategies, policies and projects aimed at reducing inequalities. But Labours attitude to the fundamental causes of inequality changed radically after Frank Dobson and Tessa Jowell left the Department of Health in 1999.

The Saving Lives: Our Healthier Nation green and white papers had explicitly adopted a holistic, socio-environmental model of the determinants of health. None of their successors followed this path most of them reverted to the downstream approaches of previous Conservative governments by focusing public health action on diseases and their immediate antecedents. While the health promotion focus of the recent Choosing Health white paper is welcome, the individualistic gimmickry that characterises its approach is unlikely to make any impact on health inequalities.

The failure of New Labours policies to reduce health inequalities can hardly be seen as bad luck. After all, we have the evidence from 18 years of divisive Conservative government. And we have a long history of gathering statistics on social class and mortality from which to learn.

This evidence showing no diminution in inequality during the 20th century teaches us that focusing on diseases is a waste of time. Just as the introduction of antibiotics improved average life expectancy but failed to reduce inequality, it has long been apparent that reducing diseases more prevalent among poor people only results in new inequalities, caused by different diseases taking their place what epidemiologists call competing risks of death.

The bottom line is that, while the NHS has to deal with the health inequalities caused by the governments policies, the root causes of those inequalities lie elsewhere in the impact of the growth-obsessed economy, the open market in trade and services, and the patriarchal culture of foreign and domestic policy which surrounds us. There is a large body of evidence demonstrating the damage such approaches cause to health, equity and social democracy.

So what is to be done? It seems unlikely that Tony Blairs Christian Democrat government will change its policies while he remains prime minister. That being so, we are unlikely in the short term to see any improvement in the root causes of health inequality. Im referring here to reductions in income and wealth inequalities, a reversal of the increasing privatisation and diminution of our welfare state, acknowledgement of, and action on the excessive masculine gender roles (aggression, risk-taking, emotional illiteracy) instilled into our young people.

These latter characteristics not only create envy, greed, and competitiveness rather than collaboration, they are also linked with greater levels of both domestic violence and political conflict. What we so badly need is to move towards a society in which those who govern us and in turn, we ourselves genuinely value, are valued by, and support each other. No area of government should be exempt from observing these principles. Once we have that, we can set realistic targets for cutting health inequalities.

Dr Alex Scott-Samuel is joint chair of the Politics of Health Group. See www.pohg.org.uk

NHS Reform: From Dr Katy Gardner, Liverpool

I have worked as a GP in inner city Liverpool for 27 years and I have fully supported most of the current governments policies on the NHS. In particular I welcome the increased funding of the NHS, the new GP contract, the principles of Choosing Health and the policies around smoking. The creation of PCTs was also in my view a very positive move.

However I feel that the government has not given the reforms it has introduced so far time to embed in the structure before introducing another rafts of reforms at breakneck speed. Both managers and clinicians are very anxious about the pace of reform and Liverpool has seen one reorganisation after another, and I believe this has been at the cost of service provision. I have seen this from the inside as I have been on the Professional Executive Committee of Central Liverpool PCT until recently.

I have been anxious from the start about the Choose and Book policy. I am not against electronic booking but I am very worried about the potential inequalities introduced into the system by the Choice part. Many of the patients I have looked after will not have a real choice of 5 providers and will have to be directed to the nearest provider. Many of them do not speak English and could not negotiate the system to get themselves to a provider elsewhere than in the inner city. Meanwhile lots of time and energy is being invested to create a system of Choice which in my view could create more inequalities.

The recent letter from Nigel Crisp terrified me. Practice based commissioning is to be introduced rapidly. Colleagues had been cautiously enthusiastic about this happening in a planned way. There is now great anxiety about getting it rolled out by the end of 2006. We understand that this is to counteract Payment by results - itself counterintuitive. That PCTs will no longer be providers but only commissioners could be catastrophic. I can only see the NHS becoming more and more fragmented, with more reorganisation and more bureaucracy.

In 1998 our practice became a salaried practice, something I wholeheartedly agreed with. I am employed currently by the PCT. In my view this was a very positive step for many practices in Liverpool and Liverpool has had great success in recruiting salaried GPs. I was always unhappy with the independent contractor status of GP as I feel this has, in the past, allowed GPs to get away with substandard care in some instances, while being paid lots of money. The advent of salaried GPs and the new GP contract has largely changed all that. I am distressed to find now, that having chosen to be employed by the PCT I may in the future be employed by some other organisation, even Boots or some private company. Although I shall do my best to avoid this (options include wooing some other NHS body, setting up a cooperative or local provider company etc) is this really the direction of travel we want to go down?

In my personal view much of the last year in Liverpool has been taken up with reorganisation of the 3 PCTs into more or less one body. Now we have Practice based commissioning which is taking up lots of managerial and analyst and practice time and then we will have the PCT changing again into a commissioning body, with further fragmentation of the system.

This government seems to be very keen on the US model of health care. I worked in the USA long ago and saw the horrendous inequalities in the system there (which we had a small glimpse of recently in New Orleans). Health in the US is worse than here and the system is more expensive.

Although I have been a Labour Party supporter for years I doubt I will be able to vote Labour at the next election if this carries on.

RICHARD DOLL

Sir Richard Doll, who died in July, aged 92, will be best remembered for his work establishing the link between smoking rates and cancer, cardiovascular disease and other disorders. Prof Colin Blakemore, Chief Executive of the MRC said that his work had done as much to save lives as the discovery of penicillin or the development of the polio vaccine. He also investigated the effects of alcohol on unborn babies, and the side effects of the birth control pill. He showed that even small amounts of ionising radiation posed a risk of leukaemia and other illness. He investigated the dangers of exposure to ultra-violet light as a possible cause of skin cancer, and recommended the avoidance of prolonged exposure to sunlight. He supported water fluoridation to prevent tooth decay.

A life member of the Socialist Health Association, he combined expertise in medicine and statistical methodology to epidemiology, in the belief that prevention was the key to significant improvements in health. The son of a GP, he took up medical research after failing a maths exam, but his cross-disciplinary approach served him well. He was a member of the Royal Commission on Environmental Pollution, chairman of the National Council on Radiation Protection, chairman of the Adverse Reaction Sub-committee on the Safety of Medicines. He was awarded the Companion of Honour in 1996.

The spirit of Richard Doll lives on in the determination to eliminate inequalities in health through sound research and the application of its findings. He will be sorely missed.

Websites of interest Derek Marcus

www.sochealth.co.uk

Everything you need to know about your MP: every speech, every vote, every outside interest which may concern you:

www.theyworkforyou.com

You simply enter your postcode.

At www.publicwhip.org.uk

you can trawl through parliamentary records of votes and find out which MPs vote which way on the issues that matter to you.

Then you can go to www.writetothem.com

from where you will be able to contact everyone who represents you from local council to European Parliament

Concerned about public money going to dubious "alternative" non-evidence-based (so called) medicine? For your guide to Quackery, Health Fraud and Intelligent decisions go to

www.quackwatch.org

This plaque was formerly on the office door at Herbert Morrison House, Walworth Road. It then moved to 16 Charles Square near Old Street, then to Toynbee Hall in Commercial Street, and now to 22 Blair Road, Manchester.

Making Public Services User Friendly For The Disadvantaged

Public services are urged by the Social Exclusion Unit to do more for the 12.4m disadvantaged people in the UK who have significantly poorer life chances than the general population. The report from the Unit, 'Improving Services, Improving Lives' shows that public service reform is not doing much for those who need them most. The Unit looked at the way services respond to disabled people, people with long-term health conditions, ethnic minority groups who experience the most acute levels of socio-economic disadvantage including Bangladeshis and Pakistanis and people with low levels of literacy.

The report highlights key areas for action including better information and communication, and giving disadvantaged people the "know how" they need to find and use public services effectively. Understanding the information provided by public services can be a challenge in itself particularly for people that struggle with reading and writing. Some information, for example, requires a reading age of nearly 17 years - well above the skills of more than 50 per cent of the population.

Another problem is interaction with frontline staff. Both users and staff of public services expect to be treated with respect, but disadvantaged people often report experiencing poor understanding and 'attitude' from staff.

FORTHCOMING EVENTS

14th November 10am to 4pm Rehabilitation conference: Are We Getting Better?

the benefits and costs of rehabilitation services, and the lack of them.

Bristol Council House, Anne McGuire MP, Minister for Disabled People; Prof Derick Wade, Oxford Centre for Enablement; Clive Martin, Ferret Information Services; Caroline Griffiths, Chair of Chartered Physiotherapists in Mental Health; Bhanu Ramaswamy, Consultant Physiotherapist in Intermediate Care, Chesterfield

19th November Noon SHA Central Council Wesleys Chapel London speaker on NHS reform

14th January Noon SHA Central Council Wesleys Chapel London speaker on regulation

We are organising 5 meetings early next year around the current reforms of the NHS. The format may vary, they will either be debates - to debate the proposition that these changes will make health inequalities better or worse, - or seminars discussing what would be needed for these reforms to deliver improvements to health inequality: If anyone knows of good speakers local to the venues please let us know.

25th JanIpswich Christchurch Tacket Street

28th Jan Bristol with Prof Julian Le Grand

3rd February Liverpool Quaker meeting house: with Dr Katy Gardner

17th February York: with Prof Paul Corrigan

20th February Toynbee Hall London

Further details will be on the website and emailed to members. If you dont have email access please let the office know if you are interested in attending and we will keep you informed.

6th March Friends House Euston Road Advice and information services for patients in the new NHS

Members are encouraged to attend all our events. If a charge is made it is considerably reduced for members. If any members are unable to meet the charge we are happy to waive it.

SHA BRANCH CONTACTS

Greater London: Huw Davies 020-8748-7284

Greater Manchester: M. Rathfelder 0161-286-1926

North East: Rita Stringfellow 0191-258-3949

Scotland: Ali Syed 0141-942-8804

Wales: Andrew Rogers01495- 307301

West of England: Paul Walker 0117-968-2205

West Midlands: John Charlton 0121-475-7700Contact the SHA

Do you have a point of view? The pages of Socialism & Health are open to everyone. All letters and articles will be considered for publication. And the SHA welcomes any other expertise or help you can offer to ensure that the SHA remains a dynamic and respected campaigning pressure group in the 21st Century.

Socialist Health Association

Director, Martin Rathfelder, 22 Blair Road, Manchester M16 8NS E-mail: admin@sochealth.co.uk

The views expressed in this journal are not necessarily those of the SHA

Articles, Letters, Announcements and Comments should be sent to Gavin Ross, 21 Connaught Road, Harpenden, Herts AL5 4TW, Tel/Fax 01582-715399 or by e-mail to gavros.ross@btopenworld.com

Deadline for next issue: 31st December 2005

gavros.ross@btopenworld.com